Barbara Delmore PhD, RN, CWCN, MAPWCA, IIWCC-NYU

Senior Nurse Scientist

Center for Innovation in the Advancement of Care

NYU Langone Health, NY, NY

Assistant Clinical Professor

Hansjӧrg Wyss, Department of Plastic Surgery

NYU School of MedicineNY, NY

Wound Care Across the Continuum: Bridging the Inpatient and Outpatient Worlds Together

Friday, September 7, 2018 • 10:00am - 11:00am

The participant will:

• Describe the issues faced by both inpatient and outpatient settings as a patient with a wound traverses through the healthcare continuum

• Differentiate these issues by reviewing case studies

Objectives

©Delmore 2018

• A patient with a wound can traverse through the healthcare continuum at any given time

“Current State of Affairs”

Home

Clinic

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• Revolving Door

• Where does the patient show up first?

“Current State of Affairs”At-Large

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• Settings

• Inpatient – e.g., hospital, LTAC, SNF

• Short-stay units, e.g., same day surgeries

• Outpatient – e.g., clinic, ambulatory setting, “home”

• Daily issues regardless of setting

• Regulation requirements & reporting

• Legal issues

• Coding issues

• Reimbursement issues

• Resources (e.g., funding, staff, supplies, equipment)

• Documentation requirements

“Current State of Affairs”

©Delmore 2018

• Potential differences:

• Expectations

• Treatment options

• Workflow

• Insurance coverage

• Resources available-services, assistance (family?), social & economic influences

• Control of situation/environment

• Similarity

• Patient with a wound

Differences & Similarities

Gap

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With a Plan:

• Wound treatment outlined for a hospitalized patient

• Same treatment recommended for the home setting

• Home services appreciates the plan

• But…can’t provide the services as specified (e.g., staffing, no WOC nurse, supplies, insurance issues)

Without a Plan:

• Patient discharged from subacute facility with a wound

• No plan in place

• Appears in a non-wound outpatient setting

“Current State of Affairs”

©Delmore 2018

The wound

• Regardless of setting, need to know:

• History/Physical

• Co-morbidities – diabetes, smoking, poor blood flow

• Wound etiology

• Healable, non-healable, or maintenance

• Consistent with patient’s goals of care

• Drives treatment

• Pain

• How has the wound been managed?

Treating the Patient With a Wound

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The Situation

• Who is in the “circle of care”

(patient/family/caregiver)

• How has the “circle” been managing the wound?

• Patient’s normal activity

• Patient’s perception of wound; family’s perception

• Embarrassed, won’t acknowledge, dementia

• Resources

• Finances

• Insurance

• Habitus

• What team members have been involved?

Treating the Patient With a Wound

©Delmore 2018

Have to treat the whole patient

• What is the best method for treating the wound?• Frequency of dressings

• Is there the financial ability to treat the wound?• Insurance coverage• Patient/family resources

• What resources are needed to treat the wound?• Home health care services (e.g., nursing, CNA, PT, OT)• Outpatient wound center• Inpatient facility

• Can the patient/family provide care prn

• Who are the interprofessional team members needed?• Registered Dietitian• Physical/Occupational Therapist• Wound care professional (e.g., MD, DPM, RN, PT)

• How can a admission/readmission be avoided?

Unveiling the Complexities

©Delmore 2018

CASE STUDIES

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• 98 year-old female

• Admitted to hospital with pneumonia, anorexia, and dehydration

• Unstageable pressure injury/ulcer to sacrum

Case Study #1AHome Hospital

©NYULH

©Delmore 2018

1. Healable, maintenance, or non-healable?

2. Hospital treatment? Continue at home?

…..If so:

Services required for home care?

Treatment managed at home?

Patient allow/accept care?

Dressing frequency?

Patient/family manage treatment?

Insurance cover?

…..If not:

Patient needs facility placement? Outpatient center?

Case Study #1a - Questions

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• Wound debrided at bedside (patient unstable)

Case Study #1b

Do the questions and concerns change?Can home medical & nursing home visits be done?Can you get hospice services?

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©NYULMC

Case study 2aHome Outpatient Oncology

• 37 year-old male

• Metastatic melanoma

• Multiple intact lesions to the right leg

• Patient complains lesions have an “itchy” sensation

©NYULMC

©Delmore 2018

Case Study #2a - Questions

1. Healable, maintenance , or non-healable?

2. Topical treatment?

3. Services needed at home?a) Dressing frequency?b) Patient/family manage?c) Insurance cover?

©Delmore 2018

Do the questions and concerns change?

• Can the patient travel to an outpatient wound center?

• Are there any costs associated with the new plan?

Case Study 2b

Outpatient Oncology Office

Outpatient Wound Center

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©NYULMC

• 34 year-old female

• Spina bifida, eating disorder, multiple falls (leg discrepancies/foot anomalies), neurogenic bladder

• Stage 4 left ischial pressure ulcer (opening & closing for 8 years)

• Lived with sister who would not allow specialty equipment or home services

• Slept on couch

• Boyfriend legally blind

• One point homeless; sleeping on subway

Case study 3 - Outpatient Wound Center ????

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• Interprofessional Team

• Social Work

• Poor Medicaid coverage

• Living arrangements

• Psychiatry

• Registered Dietitian

• DPM

• Physical Therapy

• Urologist

Case Study #3 – Patient’s Needs

• Surgical

• Rotation Flap

• Specialty bed

• Personal Care

• Ability to self-cath

• Foot Care

• Wound care

• Dressings

• Supplies

• Equipment

• Cath supplies

• Feet & other splints©Delmore 2018

• What does it take for success?

• Good planning

Summary

©Delmore 2018

Planning ahead

• Discharge planning from initial consult regardless of disposition

• Is the plan viable for the patient across the continuum?

• Re-evaluate plan

• Communication tools (e.g., phone, email, EHR)

• Interprofessional teams working together

• Coordination of efforts• Partnerships

• Home care agencies, systems• Own system

Summary

©Delmore 2018

The participant will:

• Described the issues faced by both inpatient and outpatient settings as a patient with a wound traverses through the healthcare continuum

• Differentiated these issues by reviewing case studies

Objectives Re-visited

©Delmore 2018

Barbara Delmore PhD, RN, CWCN, MAPWCA, IIWCC-NYU

Senior Nurse Scientist

Center for Innovation in the Advancement of Care

NYU Langone Health, NY, NY

Assistant Clinical Professor

Hansjӧrg Wyss, Department of Plastic Surgery

NYU School of MedicineNY, NY

Wound Care Across the Continuum: Bridging the Inpatient and Outpatient Worlds Together

Friday, September 7, 2018 • 10:00am - 11:00am